Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Health History *

Your health information affects how we can safely design your sessions. Please check your medical history or current health status.

Recent Surgery

Osteoporosis/Osteopenia (low bone density)

Heart Attack/ Coronary Bypass/ Other Cardiac Surgery

Peripheral Vascular Disease

Stroke

High Blood Pressure

Migraines / Headaches

Neck Problems

Shoulder Problems

Hip Problems

Back Problems

SI Joint Problems

Knee Problems

Ankle Problems

Foot Problems

Scoliosis

Bursitis

Arthritis

Lightheadedness or Fainting

Asthma

Hernia

Stomach or Intestinal Problems

Epilepsy/Seizures

Glaucoma

Vertigo

Fractures

Diabetes

Cancer

Fibromyalgia

Rheumatoid Arthritis

Auto-Immune Disease

Pregnancy

History of C-Section

Pelvic Floor Issues

NONE OF THE ABOVE

COVID-19 Vaccination Status *

Vaccine Status for COVID-19

Fully Vaccinated *2 Dose mRNA

Partial Vaccinated

Not Vaccinated